A multifaceted feedback strategy alone does not improve the adherence to organizational guideline-based standards: a cluster randomized trial in intensive care.

BACKGROUND: Organizational data such as bed occupancy rate and nurse-to-patient ratio are related to clinical outcomes and to the efficient use of intensive care unit (ICU) resources. Standards for these performance indicators are provided in guidelines. We studied the effects of a multifaceted feedback strategy to improve the adherence to these standards. METHODS: In a cluster randomized controlled study design the intervention ICUs received extensive monthly feedback reports, they received outreach visits and initiated a quality improvement team. The control ICUs received limited quarterly feedback reports only. We collected primary data prospectively within the setting of a Dutch national ICU registry over a 14-month study period. The target indicators were bed occupancy rate (aiming at 80 % or below) and nurse-to-patient ratio (aiming at 0.5 or higher). Data were collected per 8-h nursing shift. Logistic regression analysis was performed. For both study end points, the odds ratios (OR) for improvements at follow-up versus at baseline were calculated separately for control and intervention ICUs. RESULTS: We analyzed data on 67,237 nursing shifts. The bed occupancy rate did not improve in the intervention group compared to baseline (adjusted OR 0.88; 95 % confidence interval (CI), 0.62-1.27) or compared to control group (OR 0.67; 95 % CI 0.39-1.15). The nurse-to-patient ratio did not improve (OR 0.72; 95 % CI 0.41-1.26 compared to baseline and OR 0.65; 95 % CI 0.35-1.19 compared to control group). CONCLUSIONS: A multifaceted feedback intervention did not improve the adherence to guideline-based standards on the organizational issues bed occupancy rate and nurse-to-patient ratio in the ICU. The reasons may be a limited confidence in data quality, the lack of practical tools for improvement, and the relatively short follow-up. ISRCTN: ISRCTN50542146.

Effect of a multifaceted performance feedback strategy on length of stay compared with benchmark reports alone: a cluster randomized trial in intensive care*.

OBJECTIVE: To assess the impact of applying a multifaceted activating performance feedback strategy on intensive care patient outcomes compared with passively receiving benchmark reports. DESIGN: The Information Feedback on Quality Indicators study was a cluster randomized trial, running from February 2009 to May 2011. SETTING: Thirty Dutch closed-format ICUs that participated in the national registry. Study duration per ICU was sixteen months. PATIENTS: We analyzed data on 25,552 admissions. Admissions after coronary artery bypass graft surgery were excluded. INTERVENTION: The intervention aimed to activate ICUs to undertake quality improvement initiatives by formalizing local responsibility for acting on performance feedback, and supporting them with increasing the impact of their improvement efforts. Therefore, intervention ICUs established a local, multidisciplinary quality improvement team. During one year, this team received two educational outreach visits, monthly reports to monitor performance over time, and extended, quarterly benchmark reports. Control ICUs only received four standard quarterly benchmark reports. MEASUREMENTS AND RESULTS: The extent to which the intervention was implemented in daily practice varied considerably among intervention ICUs: the average monthly time investment per quality improvement team member was 4.1 hours (SD, 2.3; range, 0.6-8.1); the average number of monthly meetings per quality improvement team was 5.7 (SD, 4.5; range, 0-12). ICU length of stay did not significantly reduce after 1 year in intervention units compared with controls (hazard ratio, 1.02 [95% CI, 0.92-1.12]). Furthermore, the strategy had no statistically significant impact on any of the secondary measures (duration of mechanical ventilation, proportion of out-of-range glucose measurements, and all-cause hospital mortality). CONCLUSIONS: In the context of ICUs participating in a national registry, applying a multifaceted activating performance feedback strategy did not lead to better patient outcomes than only receiving periodical registry reports.

Process evaluation of a tailored multifaceted feedback program to improve the quality of intensive care by using quality indicators.

BACKGROUND: In multisite trials evaluating a complex quality improvement (QI) strategy the 'same' intervention may be implemented and adopted in different ways. Therefore, in this study we investigated the exposure to and experiences with a multifaceted intervention aimed at improving the quality of intensive care, and explore potential explanations for why the intervention was effective or not. METHODS: We conducted a process evaluation investigating the effect of a multifaceted improvement intervention including establishment of a local multidisciplinary QI team, educational outreach visits and periodical indicator feedback on performance measures such as intensive care unit length of stay, mechanical ventilation duration and glucose regulation. Data were collected among participants receiving the intervention. We used standardised forms to record time investment and a questionnaire and focus group to collect data on perceived barriers and satisfaction. RESULTS: The monthly time invested per QI team member ranged from 0.6 to 8.1 h. Persistent problems were: not sharing feedback with other staff; lack of normative standards and benchmarks; inadequate case-mix adjustment; lack of knowledge on how to apply the intervention for QI; and insufficient allocated time and staff. The intervention effectively targeted the lack of trust in data quality, and was reported to motivate participants to use indicators for QI activities. CONCLUSIONS: Time and resource constraints, difficulties to translate feedback into effective actions and insufficient involvement of other staff members hampered the impact of the intervention. However, our study suggests that a multifaceted feedback program stimulates clinicians to use indicators as input for QI, and is a promising first step to integrating systematic QI in daily care.

Needs and barriers to improve the collaboration in oral anticoagulant therapy: a qualitative study.

BACKGROUND: Oral anticoagulant therapy (OAT) involves many health care disciplines. Even though collaboration between care professionals is assumed to improve the quality of OAT, very little research has been done into the practice of OAT management to arrange and manage the collaboration. This study aims to identify the problems in collaboration experienced by the care professionals involved, the solutions they proposed to improve collaboration, and the barriers they encountered to the implementation of these solutions. METHODS: In the Netherlands, intensive follow-up of OAT is provided by specialized anticoagulant clinics (ACs). Sixty-eight semi-structured face-to-face interviews were conducted with 103 professionals working at an AC. These semi-structured interviews were transcribed verbatim and analysed inductively. Wagner's chronic care model (CCM) and Cabana's framework for improvement were used to categorize the results. RESULTS: AC professionals experienced three main bottlenecks in collaboration: lack of knowledge (mostly of other professionals), lack of consensus on OAT, and limited information exchange between professionals. They mentioned several solutions to improve collaboration, especially solutions of CCM's decision support component (i.e. education, regular meetings, and agreements and protocols). Education is considered a prerequisite for the successful implementation of other proposed solutions such as developing a multidisciplinary protocol and changing the allocation of tasks. The potential of the health care organization to improve collaboration seemed to be underestimated by professionals. They experienced several barriers to the successful implementation of the proposed solutions. Most important barriers were the lack motivation of non-AC professionals and lack of time to establish collaboration. CONCLUSIONS: This study revealed that the collaboration in OAT is limited by a lack of knowledge, a lack of consensus, and a limited information exchange. Education was identified as the best way to improve collaboration and considered a prerequisite for a successful implementation of other proposed solutions. Hence, the implementation sequence is of importance in order to improve the collaboration successfully. First step is to establish alignment regarding collaboration with all involved professionals to encounter the lack of motivation of non-AC professionals and lack of time.

Evaluating the effectiveness of a tailored multifaceted performance feedback intervention to improve the quality of care: protocol for a cluster randomized trial in intensive care.

BACKGROUND: Feedback is potentially effective in improving the quality of care. However, merely sending reports is no guarantee that performance data are used as input for systematic quality improvement (QI). Therefore, we developed a multifaceted intervention tailored to prospectively analyzed barriers to using indicators: the Information Feedback on Quality Indicators (InFoQI) program. This program aims to promote the use of performance indicator data as input for local systematic QI. We will conduct a study to assess the impact of the InFoQI program on patient outcome and organizational process measures of care, and to gain insight into barriers and success factors that affected the program's impact. The study will be executed in the context of intensive care. This paper presents the study's protocol. METHODS/DESIGN: We will conduct a cluster randomized controlled trial with intensive care units (ICUs) in the Netherlands. We will include ICUs that submit indicator data to the Dutch National Intensive Care Evaluation (NICE) quality registry and that agree to allocate at least one intensivist and one ICU nurse for implementation of the intervention. Eligible ICUs (clusters) will be randomized to receive basic NICE registry feedback (control arm) or to participate in the InFoQI program (intervention arm). The InFoQI program consists of comprehensive feedback, establishing a local, multidisciplinary QI team, and educational outreach visits. The primary outcome measures will be length of ICU stay and the proportion of shifts with a bed occupancy rate above 80%. We will also conduct a process evaluation involving ICUs in the intervention arm to investigate their actual exposure to and experiences with the InFoQI program. DISCUSSION: The results of this study will inform those involved in providing ICU care on the feasibility of a tailored multifaceted performance feedback intervention and its ability to accelerate systematic and local quality improvement. Although our study will be conducted within the domain of intensive care, we believe our conclusions will be generalizable to other settings that have a quality registry including an indicator set available. TRIAL REGISTRATION: Current Controlled Trials ISRCTN50542146.

Differences in patient outcomes and chronic care management of oral anticoagulant therapy: an explorative study.

BACKGROUND: The oral anticoagulant therapy - provided to prevent thrombosis - is known to be associated with substantial avoidable hospitalization. Improving the quality of the oral anticoagulant therapy could avoid drug related hospitalizations. Therefore, this study compared the patient outcomes between Dutch anticoagulant clinic (AC) regions taking the variation in chronic care management into account in order to explore whether chronic care management elements could improve the quality of oral anticoagulant therapy. METHODS: Two data sources were combined. The first source was a questionnaire that was send to all ACs in the Netherlands in 2008 (response = 100%) to identify the application of chronic care management elements in the AC regions. The Chronic Care Model of Wagner was used to make the concept of chronic care management operational. The second source was the report of the Dutch National Network of ACs which contains patient outcomes of the ACs. RESULTS: Patient outcomes achieved by the ACs were good, yet differences existed; for instance the percentage of patients in the appropriate therapeutic ranges varied from 67 to 87% between AC regions. Moreover, differences existed in the use of chronic care management elements of the chronic care model, for example 12% of the ACs had multidisciplinary meetings and 58% of the ACs had formal agreements with at least one hospital within their region. Patient outcomes were significantly associated with patient orientation and the number of specialized nurses versus doctors (p-values < 0.05). Furthermore, the overall extent to which chronic care management elements were applied was positively associated with patient outcomes (p-values < 0.05). CONCLUSIONS: Substantial differences in the patient outcomes as well as chronic care management of oral anticoagulant therapy existed. Since our results showed a positive association between overall application of chronic care management and patient outcomes, additional research is needed to fully understand the working mechanism of chronic care management.

Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis.

BACKGROUND: Health-care-associated infection is the most frequent result of unsafe patient care worldwide, but few data are available from the developing world. We aimed to assess the epidemiology of endemic health-care-associated infection in developing countries. METHODS: We searched electronic databases and reference lists of relevant papers for articles published 1995-2008. Studies containing full or partial data from developing countries related to infection prevalence or incidence-including overall health-care-associated infection and major infection sites, and their microbiological cause-were selected. We classified studies as low-quality or high-quality according to predefined criteria. Data were pooled for analysis. FINDINGS: Of 271 selected articles, 220 were included in the final analysis. Limited data were retrieved from some regions and many countries were not represented. 118 (54%) studies were low quality. In general, infection frequencies reported in high-quality studies were greater than those from low-quality studies. Prevalence of health-care-associated infection (pooled prevalence in high-quality studies, 15·5 per 100 patients [95% CI 12·6-18·9]) was much higher than proportions reported from Europe and the USA. Pooled overall health-care-associated infection density in adult intensive-care units was 47·9 per 1000 patient-days (95% CI 36·7-59·1), at least three times as high as densities reported from the USA. Surgical-site infection was the leading infection in hospitals (pooled cumulative incidence 5·6 per 100 surgical procedures), strikingly higher than proportions recorded in developed countries. Gram-negative bacilli represented the most common nosocomial isolates. Apart from meticillin resistance, noted in 158 of 290 (54%) Staphylococcus aureus isolates (in eight studies), very few articles reported antimicrobial resistance. INTERPRETATION: The burden of health-care-associated infection in developing countries is high. Our findings indicate a need to improve surveillance and infection-control practices. FUNDING: World Health Organization.

Implementing quality indicators in intensive care units: exploring barriers to and facilitators of behaviour change.

BACKGROUND: Quality indicators are increasingly used in healthcare but there are various barriers hindering their routine use. To promote the use of quality indicators, an exploration of the barriers to and facilitating factors for their implementation among healthcare professionals and managers of intensive care units (ICUs) is advocated. METHODS: All intensivists, ICU nurses, and managers (n = 142) working at 54 Dutch ICUs who participated in training sessions to support future implementation of quality indicators completed a questionnaire on perceived barriers and facilitators. Three types of barriers related to knowledge, attitude, and behaviour were assessed using a five-point Likert scale (1 = strongly disagree to 5 = strongly agree). RESULTS: Behaviour-related barriers such as time constraints were most prominent (Mean Score, MS = 3.21), followed by barriers related to knowledge and attitude (MS = 3.62; MS = 4.12, respectively). Type of profession, age, and type of hospital were related to knowledge and behaviour. The facilitating factor perceived as most important by intensivists was administrative support (MS = 4.3; p = 0.02); for nurses, it was education (MS = 4.0; p = 0.01), and for managers, it was receiving feedback (MS = 4.5; p = 0.001). CONCLUSIONS: Our results demonstrate that healthcare professionals and managers are familiar with using quality indicators to improve care, and that they have positive attitudes towards the implementation of quality indicators. Despite these facts, it is necessary to lower the barriers related to behavioural factors. In addition, as the barriers and facilitating factors differ among professions, age groups, and settings, tailored strategies are needed to implement quality indicators in daily practice.

Using quality indicators to improve hospital care: a review of the literature.

PURPOSE: To review the literature concerning strategies for implementing quality indicators in hospital care, and their effectiveness in improving the quality of care. DATA SOURCES: A systematic literature study was carried out using MEDLINE and the Cochrane Library (January 1994 to January 2008). STUDY SELECTION: Hospital-based trials studying the effects of using quality indicators as a tool to improve quality of care. DATA EXTRACTION: Two reviewers independently assessed studies for inclusion, and extracted information from the studies included regarding the health care setting, type of implementation strategy and their effectiveness as a tool to improve quality of hospital care. RESULTS: A total of 21 studies were included. The most frequently used implementation strategies were audit and feedback. The majority of these studies focused on care processes rather than patient outcomes. Six studies evaluated the effects of the implementation of quality indicators on patient outcomes. In four studies, quality indicator implementation was found to be ineffective, in one partially effective and in one it was found to be effective. Twenty studies focused on care processes, and most reported significant improvement with respect to part of the measured process indicators. The implementation of quality indicators in hospitals is most effective if feedback reports are given in combination with an educational implementation strategy and/or the development of a quality improvement plan. CONCLUSION: Effective strategies to implement quality indicators in daily practice in order to improve hospital care do exist, but there is considerable variation in the methods used and the level of change achieved. Feedback reports combined with another implementation strategy seem to be most effective.

Quality measurement at intensive care units: which indicators should we use?

OBJECTIVE: This study was conducted to develop a set of indicators that measure the quality of care in intensive care units (ICU) in Dutch hospitals and to evaluate the feasibility of the registration of these indicators. METHODS: To define potential indicators for measuring quality, 3 steps were made. First, a literature search was carried out to obtain peer-reviewed articles from 2000 to 2005, describing process or structure indicators in intensive care, which are associated with patient outcome. Additional indicators were suggested by a panel of experts. Second, a selection of indicators was made by a panel of experts using a questionnaire and ranking in a consensus procedure. Third, a study was done for 6 months in 18 ICUs to evaluate the feasibility of using the identified quality indicators. Site visits, interviews, and written questionnaires were used to evaluate the use of indicators. RESULTS: Sixty-two indicators were initially found, either in the literature or suggested by the members of the expert panel. From these, 12 indicators were selected by the expert panel by consensus. After the feasibility study, 11 indicators were eventually selected. "Interclinical transport," referring to a change of hospital, was dropped because of lack of reliability and support for further implementation by the participating hospitals in the study. The following structure indicators were selected: availability of intensivist (hours per day), patient-to-nurse ratio, strategy to prevent medication errors, measurement of patient/family satisfaction. Four process indicators were selected: length of ICU stay, duration of mechanical ventilation, proportion of days with all ICU beds occupied, and proportion of glucose measurement exceeding 8.0 mmol/L or lower than 2.2 mmol/L. The selected outcome indicators were as follows: standardized mortality (APACHE II), incidence of decubitus, number of unplanned extubations. The time for registration varied from less than 30 minutes to more than 1 hour per day to collect the items. Among other factors, this variation in workload was related to the availability of computerized systems to collect the data. CONCLUSION: In this study, a set of 11 quality indicators for intensive care was defined based on literature research, expert opinion, and testing. The set gives a quick view of the quality of care in individual ICUs. The availability of a computerized data collection system is important for an acceptable workload.

Differences in perinatal mortality and suboptimal care between 10 European regions: results of an international audit.

OBJECTIVE: A European concerted action (the EuroNatal study) investigated the background of differences in perinatal mortality between countries of Europe. The study aimed to determine the contribution of differences in quality of care, by looking at differences in the presence of suboptimal factors in individual cases of perinatal death. DESIGN: Retrospective audit study. SETTING: Regions of 10 European countries. POPULATION: 1619 cases of perinatal death. METHODS: Perinatal deaths between 1993 and 1998 in regions of 10 European countries were identified. Reviewed were singleton fetal deaths (28 or more weeks of gestational age), intrapartum deaths (28 or more weeks) and neonatal deaths (34 or more weeks). Deaths with (major) congenital anomalies were excluded. Cases were blinded for region and an international audit panel reviewed them using explicit audit criteria. MAIN OUTCOME MEASURES: Presence of suboptimal factors. RESULTS: The audit covered 1619 cases of perinatal death, representing 90% of eligible cases in the regions. Consensus was reached on 1543 (95%) cases. In 715 (46%) of these cases, suboptimal factors, which possibly or probably had contributed to the fatal outcome, were identified. The percentage of cases with such suboptimal care factors was significantly lower in the Finnish and Swedish regions compared with the remaining regions of Spain, the Netherlands, Scotland, Belgium, Denmark, Norway, Greece and England. Failure to detect severe IUGR (10% of all cases) and smoking in combination with severe IUGR and/or placental abruption (12%) was the most frequent suboptimal factor. There was a positive association between the proportion of cases with suboptimal factors and the overall perinatal mortality rate in the regions. CONCLUSIONS: The findings of this international audit suggest that differences exist between the regions of the 10 European countries in the quality of antenatal, intrapartum and neonatal care, and that these differences contribute to the explanation of differences in perinatal mortality between these countries. The background to these differences in quality of care needs further investigation.

Birth weight and perinatal mortality: a comparison of "optimal" birth weight in seven Western European countries.

BACKGROUND: Previous studies have suggested that a population's entire birth weight distribution may be shifted towards higher or lower birth weights, and that optimal birth weight may be lower in populations with a lower average birth weight. We evaluated this hypothesis for seven western European countries. METHODS: We obtained data on all singleton births (N = 1,372,092) and extended perinatal deaths (stillbirths plus neonatal deaths; N = 7,900) occurring in Finland, Sweden, Norway, Denmark, Scotland, the Netherlands, and Flanders (Belgium) in 1993-1995. We assessed whether countries differed in the mode of their birth weight distribution and in the birth weight associated with the lowest perinatal mortality, and then correlated the two. RESULTS: Substantial international differences were found in the mode of the birth weight distribution, which ranged between 3384 gm in Flanders and 3628 gm in Finland. The position of the minimum of the perinatal mortality curve also differed considerably, ranging between 3755 gm in Flanders and 4305 gm in Norway. There was a strong relation between the two: for every 100 gm increase in modal birth weight, optimal birth weight was 170 gm higher (95% confidence interval = 104-236 gm). CONCLUSIONS: Our results confirm those of previous studies that compared two populations. To improve the identification of small babies at high risk of perinatal death, population-specific standards for birth weight should be developed and used.